A new form of the medical record of a patient receiving medical care in inpatient conditions, in a day hospital as a criterion for the quality and safety of medical activity

Abstract

Objective: to conduct a comparative analysis of the previously valid “Card” with a new form of “Card” filled in for patients receiving medical care in a hospital setting with the focus of the attention of practitioners on the new paragraphs of this document.Materials and methods: a comparative analysis of the medical record of an inpatient patient approved by the order of the Ministry of Health of the USSR dated October 4, 1980 was carried out. No. 1030 “On Approval of Forms of primary Medical Documentation of healthcare institutions” and the Medical record of a patient receiving medical care in inpatient conditions, in a Day hospital, approved by the Order of the Ministry of Health of the Russian Federation dated August 5, 2022 No. 530n “On Approval of Unified Forms of medical documentation used in medical organizations providing medical care in inpatient conditions, in the conditions of the day hospital and the procedures for their management”.Results: based on the results of the study of two forms of “Cards”, the advantages of the new form have been established, which improve the quality of medical documentation and, as a result, taking into account the fact that the ECMP is carried out according to medical documentation, lead to a reduction in the risks of imposing financial sanctions on medical organizations during the relevant examinations. In particular, a number of shortcomings of the new form of the “Map” are indicated, requiring additional study and discussion with possible additions in the future.Conclusions: the relevance of the examination of the quality of medical care, which, as a rule, is carried out according to the medical documentation of completed cases, is reflected. It is noted that the correct filling in of all the provided graphs and lines will minimize the number of defects in the registration of medical documentation, which in turn will reduce the financial sanctions imposed on medical organizations during the ECMP.

Keywords

• medical organization
• medical record
• inpatient care
• medical care
• quality
• quality examination
• medical documentation
• quality control
• diagnosis